Food Allergen Introductions during Weaning

There seems to be a lot of confusion about when to introduce food allergens in babies’ diets during weaning. I do not blame parents,  as this is a very confusing area and there is a lot of conflicting advice around. I am going to focus today on the general population, not on babies with an atopic background (meaning babies that have eczema, or a strong immediate family history of allergies – asthma, hayfever, eczema) or those with existing food allergies. I will write a blog entry about that particular population later.

Although the main focus has been on peanuts and the introduction of this in babies diets, there are many more allergens to introduce during early childhood including, wheat, egg, cow’s milk, shellfish, soya, sesame and tree nuts. In a previous blog entry, I have debated the age of solid introduction, so will not repeat this in this section. Once you have started with solid introduction, which should not be later than 6 months of age, there is absolutely no evidence to delay any of the allergens. Although it’s pretty easy to introduce milk (yoghurt, cheese) and wheat, a lot of parents get stuck there and do not move on with other allergen introductions as this is either not part of their normal diet (i.e. common feedback about shellfish) or they think it is not appropriate for a child to eat. Egg is a great protein source and as long as its well-cooked, should be introduced as part of your baby’s diet (together with other allergens) soon after weaning is commenced. Nut butters (peanut butter and other tree nut butters) are also very nutritious and you can find sugar and salt free versions from many shops. This can be incorporated in the porridge in the morning, on a toast soldier or many of my children have this on a spoon and lick it off as a snack – again this should be earlier rather than later (soon after weaning has been commence). In regards to soya, most common comment I get is that families do not eat soya products. Well, I would challenge you to start looking at the ingredients of foods! Did you realise that 80% of standard breads in the UK contain soya, so this would be an automatic introduction of soya in a child’s diet if they have bread. Sesame also is an easy one to introduce as the majority of my parents at some point provide hummus, which contains tahini (sesame paste). Lastly the question about shellfish – I know this is not a common one to introduce in children’s diet and can be tricky in regards to sourcing safe and good quality. My advice would be, if you have this in your family’s diet, introduce earlier rather than later.

Last tip, once you have introduced an allergen successfully, do keep it in your child’s diet on a regular basis, to ensure that tolerance is maintained.

Cooking for my baby and toddler – practical tips

I have decided this week to write about cooking, reheating, boiling and not boiling water  for your baby/toddler as it is still question that many parents have.

I think the most common question I get is whether to boil/steam foods and if they are older whether its okay to roast. There are no specific guidelines on the cooking methods for children and as this mainly depends on whether you are using the baby led weaning approach (see my previous blog entry under Introduction of Solids) or whether you are introducing solids in the more traditional way (i.e. puree and then lumpy). Of course with cooking, you will loose some of the heat sensitive vitamins, but its important initially to have a texture that is suitable for your child. In particular in the initial phases of weaning, vitamins and minerals will come mainly from breast milk or formula, so cooking the vegetables for example really softly (i.e. very long) to a manageable texture is not going to lead to vitamin deficiencies. As a side, energy/protein/carbohydrate and fat content does not change with heating and most minerals (i.e. calcium) are heat stable.

In regards to equipment, I find steamers really useful and of course a good hand-blender. There are many baby steamers that have integrated blenders. I have tried a couple and find most okay, but when you want to prepare bigger volumes for freezing for example, I find their container size quite small. So before you go an buy something special, think about the future and whether you envisage cooking fresh each day (then smaller container makes sense) or making larger batches. When it comes to the texture, if its too thick you can either  add your breast milk, formula or the cooking water to thin it to a texture tolerated by your baby. However, if you are planning to freeze these in batches, its better to not add your breast milk/or formula to the foods you are freezing but rather do this fresh after reheating.

Okay, so now to cooking and reheating. Firstly the cooked food should be cooled as quickly as possible and then frozen  and then place this into the fridge or freezer. Foods kept in the fridge, should be eaten within 2 days. Foods that are frozen should ideally be defrosted first (for example take out and place in fridge) and then reheat to piping hot and let it cool down to a temperature tolerated by your baby. I get a lot of questions about using the microwave. Reheating in the microwave is not ideal, as it often creates heat pockets and areas that are not properly heated. If you want to use the microwave, then stir the food whilst heating so that you make sure that all areas are properly heated through. Foods that have been reheated and not eaten should not be reheated/used again.

More information on this is on this NHS website.

In regards to water; in the UK we follow the WHO guidelines for mixing of formula, which is to mix formulas with cooled boiled water that is about 70C. You reach this temperature after boiling the kettle and letting it stand for about 30 min (see this site for more information). Fully breastfed babies do not need any water until they’ve started eating solid foods. Bottle-fed babies may need some extra water in hot weather. For babies under six months, use water from the mains tap in the kitchen, boil this water and then cool as per guidelines above regarding temperature. Water for babies over six months doesn’t need to be boiled, however if your child is immunocompromised (has an illness/diagnosis effecting their health) then you may be advised by your healthcare professional to boil until 1 year of age. Bottles and teats need to continue to be sterilised until a baby is 12 months of age.

Bottled water is not recommended for making up formula feeds as it may contain too much salt (sodium) or sulphate. It does however happen when travelling that tap water is not safe and you do not have a choice. If this is the case, its best to have a discussion with your healthcare professional to discuss which bottled water has low sodium and also how to establish what is high/low sodium as your healthcare professional may not know the names of bottled waters outside of UK/EU. This website may be useful for you.

 

Is rice safe for my baby?

Over the weekend my inbox was filled with e-mails by worried parents over the safety of rice in their baby’s diet. It did not take me long to figure out why this happened, as BBC online had an article on the safety of rice in children featuring Prof. Meharg, who is well known in the field of arsenic research, in particular related to arsenic in rice.

So what is the concern. Arsenic exists in soil and small amounts can get into food, though in general these levels are so low that they are not a cause for concern. However rice is different from other crops, as it is grown under flooded conditions. This makes the arsenic in the soil more readily available so that more can be absorbed into the rice grains.

Already in 2008 the Food Standard Agency (see FSA policy on rice and arsenic) has put in place guidelines for the use of rice milk, which should not be used < 4.5 years of age. In 2015 the EU put in place legislation on maximum limits of inorganic arsenic in rice and rice products and these legal limits have been applied since 2016. The FSA did a survey of infant foods in 2016 and we are awaiting there results.

Prof. Meharg, assessed many brands of baby rice, rice crackers and rice cereals from the UK (between 2014 and March 2016) and found that in some the inorganic arsenic was higher than the recommended levels and in particular this was found in products that contained whole rice (arsenic is mainly concentrated at the surface of the whole grain) and were often associated with organic rice products. One has to take into account that legal limits were only implemented since 2016, so this study may have included products prior to these limits being implemented. Similar data exists from the USA.

I am sure though you want to know what to do now with rice in your baby’s diet? Unfortunately no official body has  yet come out with any guidelines (outside of rice milk guidelines that were published by the FSA a couple of years ago) on general rice consumption for children, so what I am going to provide you in this blog entry is my own opinion on what to do (based on the data that we have) and also some of the practical advice from Prof. Meharg in the BBC article. We hopefully will get more official guidance, as soon as the FSA has their data published.

  1. Do not use rice milk as alternative 4.5 years of age
  2. Keep rice intake in children to max 2-3x per week and if used soak in a lot of water ideally overnight (throw water away) or if not time for soaking cook using a lot of water (5:1 ratio) – this significantly reduces the arsenic content
  3. Try using other baby cereals than baby rice – millet, quinoa, oat ect
  4. Be aware the whole grain rice may have more inorganic arsenic

 

Post-traumatic experience leading to feeding difficulties

Today will be my last entry on the causes of feeding difficulties. The last cause is a traumatic experience with food, that on either parent or child’s side causes the avoidance of foods. The most common reason I see for feeding difficulties related to trauma, is following a choking episode on certain foods. It does sometimes happen that with the introduction of lumpier textures, a child gags, becomes quite red in the face and in some cases vomits. Some parents experience this quite traumatic and this can lead to a reluctance to introduce textured foods, which means that it can lead to a delay in the acceptance of texture. If this were to happen to your child there are a few simple steps you can take. First of all, I usually advise parents to do a first aid course just to provide them with the comfort that they will be able to hand a situation like this.

Most importantly, do not give up on texture. Melt-in-the-mouth foods  (like the maize puffs for children) are often a really good first step to get texture into a child after a negative experience. These foods help with feeling texture and chewing (an essential skill), but before a child can choke/gag they melt and become a puree. I have often also suggested the use of a teething net (you place food in this net and your child can chew) for a week or 2 with food, just to get your confidence. Remember, there is a window of opportunity of introducing texture and that is before 10 months of age, after this it can be really difficult and some children become texture hypersensitive.

Children can also have traumatic experiences with food, which often leads to food refusal. Choking can be just as traumatic for a child as a parent. In addition, children that experience allergic reactions to foods often avoid those foods and foods that look the same/have the same texture/taste. It is therefore important when a child has a negative experience with food, to ensure you do not complete avoid the food (outside of a real food allergy of course)/similar foods but to offer food on the table of the high chair in a non threatening way, so that they still see the food is in front of them and get the message, that the food is safe and in their own time they can trial this again.

Most importantly, the reaction of parents to a food-traumatic experience can deter a child from having this food again. So if you see your child is gagging and spitting out foods, although it may be very stressful for you as a parent, try to handle this in a calm manner as a child will try to avoid similar feeding situation like this, which may entail avoiding foods.

 

The issue about salt in children

The question about salt comes up very frequently from parents I talk to, in particular if babies are above 1 year of age. Before 1 year, everybody has accepted that a “no salt policy” is a good one for baby food, but somehow there is this thinking that something magical happens at the age of one and suddenly salt intake can be totally liberalised. Of course kidneys mature with age and the amount of salt tolerated increases, but the idea behind the guidelines for reducing salt intake is also to raise a new generation of adults that are not as salt dependent as many of us are and therefore become healthier adults.

It is well known in adults that excessive salt intake affects blood pressure, but new research has shown that high salt intake in children may predispose children to high blood pressure, osteoporosis, respiratory illness (i.e. asthma), stomach cancer and obesity. So how much can your child have? The following are recommended intakes for the UK, but other EU countries have similar guidelines.

0-6 month: < 1 g per day

6-12 months: 1 g/day

1-3 years: 2 g/day

4-6 years: 3 g/day

7-10 year: 5 g/day

11 years and above: 6 g/day (adult requirements)

 Simple tips for reducing salt in your toddler’s diet:

  • Do not add salt to food – you can use herbs, spices and garlic/onion to make the food really yummy
  • Be careful of adult type crisp/salty crackers
  • Be careful of sauces/stock – you can find baby stock that does not have salt added and even better make your own
  • Smoked salmon, ham, cheese, bacon and many sausages contain a lot of salt, so best to keep the intake limited of these foods
  • You can also find a lot of salt in bread, snack and even breakfast cereals – food companies in the UK have really improved, but its important to be aware of hidden sources

How to read labels?

Firstly you need to know how to convert salt to sodium and visa versa, as many of the labels use sodium rather than salt.

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Salt = sodium x 2.5 – so if something contains 2.4g of sodium, it means it contains 6 g of salt. Be careful as often sodium is put in mg, so 2400 mg of sodium = 6 g of salt. Let me give you some further examples: if a product per 100 g contains 300 mg of sodium, this is 0.3g sodium x 2.5 = 0.75g of salt or if the product contains 0.2 g of sodium = 0.5g of salt. Hope this makes sense.

Many products now use a traffic light system to indicate salt content and are provided per 100g portion of the specific food.

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  • High is more than 1.5g salt (0.6g sodium) per 100g. These foods may be colour-coded red.
  • Medium is between 0.3 (0.1 sodium) and 1.5 g (0.6 g sodium) salt per 100g. These foods may be colour-coded in amber
  • Low is 0.3g salt (0.1g sodium) or less per 100g. These foods may be colour-coded green.

 

Useful Sites/leaflets

NHS Live Well Salt Guideline

You will see that the UK has published  2017 salt reduction targets for foods like ham, bread and other general products, which should help all of us in the future. You can read them here.

Tastes, textures and colours during weaning

Eating for us and for babies is a sensory experience, which is often forgotten. I frequently hear that a food is rejected because of the taste, but it could actually be the texture, the temperature, the colour of the food and also the environment that leads to rejection. It is therefore important to take this into account when you feed your baby.

There is a “window of opportunity” when babies are more open to new tastes and textures, which is usually from (5)6-10 months. During this period, they will be open to trial new foods. It is therefore important when you start with weaning foods, to constantly introduce new foods and from 6 months on start introducing texture. Try to also change the temperature, that your baby is used to eating foods that are hot or cold. This may become very  useful, for those days when you are out and about and can not heat the food up to the perfect temperature. Most babies will prefer sweet foods; as such you should not be disheartened if they do not like your green bean and broccoli mixture the first time you give it to them. It is important to repeat these foods and repeat them a lot…..it takes at least 15 x before some rejected foods are accepted.

When it comes to textures, whether you follow the baby led weaning approach or the traditional approach, texture is important and by 10 months ideally children should have a good variety of foods they can feed themselves by hand. Of course you are not expecting them to spoon feed at this age! Finger feeding is a messy affair, but good to let them explore and mess as this is not only a way for them to discover textures but also to enjoy the meal and feel independent.

Remember that babies look at colour as well and often choose their foods on how they look. “Mush” may therefore not always be as attractive as the food on your plate (which they may try to grab), which is colourful and plated out separately. So if they reject their mix, do try finger foods separately.

Finally, it’s a myth that babies like bland food.  Of course that does not mean you are going to add salt to the food, but there is no reason for you to not use garlic, onion, basil, rosemary and all kinds of exiting herbs and spices. I often get parents that are surprised that their child likds olives or enjoyed some curry from their plate, but this is normal, depending on the mother’s diet they would have been exposed to flavours in the womb and through breast milk. Therefore, be adventurous and add herbs and spices that are normally part of your diet to their food.

Most importantly, let your baby enjoy meal times!

How do I get in the nutrients?

I wrote on Sunday about portion sizes in infants between 6-12 months and ratios of protein to carbs and vegetables/fruit. I often get also questions about ensuring that my child “gets everything they need” from food. Food intake is of course more than just achieving energy, protein and fat intake but also making sure your baby has sufficient vitamins and minerals. Without these your child can not achieve optimal growth and development (including brain, muscle, eye and others), in addition the immune system requires vitamins and minerals to function. When you plan a meal, think about the variety of colours of the foods you are giving – sounds mad, but it is easy and works. Fruit and vegetables of different colours tend to have different vitamins and minerals and complement each other. Red and white meat and white and pink fish also have differences in their nutrient content. For example, lamb with potato and carrots and spinach – here you have some protein rich in iron, a carbohydrate source and vegetable sources rich in vitamin A, iron, folic acid and vitamin C. Compare this to a meal of chicken, with potato and sweet corn and cauliflower – you do have a protein source that has iron and a carbohydrate source, but you do not have a vegetable source high in vitamin A (yellow/orange or dark green) for example. If you replace the cauliflower with broccoli you will make this meal much more nutritious….and also more colourful. Another example is pasta with peas and salmon – 3 colours and each provides totally different vitamins and minerals. Remember that 60% of eating occurs through the eyes. So its important to ensure that your baby is exposed to different colours of foods (including textures and temperatures) to develop their acceptance of different variety of foods in the future. Now what about fruit? Banana is a favourite for all mothers, as it is convenient and you can puree, mash or give it as pieces. I think it is a great fruit to always have as a back-up. You can use a banana as one portion of fruit per day, but you do not want to give three portions of bananas as fruit/day, because this would provide you with exactly the same nutrients. So again looking at colours you can vary the nutrient content easily – banana, mango and apple – 3 different fruit, different colours and different vitamins and minerals. Below is a photo of a baby bowl with different colours of foods at the ratios previously discussed.

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What is a “portion of food” for a baby

Now the topic of food portions in young babies (6 months – 1 year) is very close to my heart, as I think most tears in my practice have been cried about my “baby not eating enough”. What is enough for a baby when it comes to food? Is it what the food companies put in a jar/pouch? Is it what as a parent you feel is enough for your child? I can tell you certainly that what is in a jar/pouch is not a portion, so do not worry if your child does not finish this. Also, what you are dishing up in most cases will also not be a right portion for your baby – because this is highly influenced by  your own eating habits (we measure our babies portion to what we would eat). It is a myth that for babies < 1 year of age you have a “magical portion size” for all foods, as sometimes a 6 month old baby can be 6 kg and sometimes 4 kg, surely you would not expect them to eat the same?

So what is a portion? Firstly between 6-12 months you are introducing solids and then expanding the variety, whilst milk intake slowly reduces as solid volume goes up. In the initial phase its all about tastes and textures and really ensuring that your child gets exposed to a wide variety of different flavours. Of course as the variety of foods increase, the nutritional contributions of weaning foods also increases. In the vast majority of babies, they have very good appetite and satiety control and generally when they signal hunger they will eat and they will stop when they are not hungry. The ideal feeding style for parents is therefore “responsive feeding” – which means you are listening to your child’s cues and respond with portions sizes according to their hunger. Other feeding styles include indulgent, controlling and neglectful feeding, which all have a negative impact on your baby’s feeding – I will discuss these further when we get to feeding difficulties. Hand in hand with a responsive feeding style goes growth monitoring, if your child grows well, you can be assured that you are getting sufficient energy and protein in, if weight gain is excessive, then they are getting too much. When you have introduced a good variety of foods into your baby’s diet you can start looking at proportions – 1/5 protein, 2/5 carbs and 2/5 vegetables. This will ensure that you have sufficient non-protein energy for the protein to be used for growth and development.

Of course there are always exceptions when it comes to a appetite and satiety. In a small number of young children there can be a disregulation of appetite and satiety where professional help is required. On the other hand when your child is unwell, their food intake is altered and  you need to respect that, because as adults when we are unwell we also do not want to eat. Can you imagine somebody sitting in front of you when you have the flu and forcing food down you?!! There are also medical diagnoses that affect appetite and satiety, including non-IgE mediated gastrointestinal food allergies (which I will discuss in another blog entry) and other gastrointestinal diseases. If your baby’s growth drops down centiles you definitely need to speak to a healthcare professional.

Now, for toddlers > 1 year of age there are some portion sizes,  which the Infant and Toddler Forum have published and they regularly tweet photos of portion sizes which help put your portions into perspective. Again, a big boy may eat more than recommended portion sizes whereas a petite girl may eat less, so looking at the portions is a great guide, but also take your child’s appetite and satiety into account.  I will write more on older children and food intake in future blog entries, as behaviour does set in when they are older so eating can often be a difficult.

Introduction of Complementary Foods

The introduction of solids (also called weaning or complementary feeding) has become quite a complex topic for both healthcare professionals and parents. This is most probably related to the fact that although we have the World Health Organization (WHO) guidelines on complementary feeding many other health organizations have published their own guidelines on weaning, which do not reflect the same information as the WHO. Add on to this the worry about the increase in food allergy and confusion when to start solids to prevent the development of these and you have a perfect recipe for confusion.

So lets start with the basics: the WHO recommends that weaning is commenced at 6 months of age, with this recommendation being  backed up by a very good systematic review of many studies indicating that breastfeeding exclusively until this age provides a baby with all the nutrition that they need and has the added benefit of reducing infections (see blog post on the benefits of breast milk). So the ideal from the WHO perspective is to breast feed exclusively until 6 months and then introduce solids. This is the advice currently also supported by the Department of Health in the UK. However, the European Society of Paediatric Gastroenterology Hepatology and Nutrition and the American Academy of Pediatrics both recommend introduction of solids occur between 4-6 months of age, when the child is ready. The latter recommendations are also based on really good research indicating that too early (< 17 weeks) or too late (> 26 week) weaning can also introduce a multitude of problems, which I will discuss under feeding difficulties, food allergies and micro-nutrient deficiencies in future blog entries.

So what are parents supposed to do? For me as a healthcare professional the most important aspect to commencing solids in any infant is not to do any harm, so DEFINITELY no solids < 17 weeks and it is important NOT to delay solid introduction beyond 26 weeks. In between this age, each baby will indicate whether they are ready to be weaned. Generally this would include being able to sit upright and hold their head in a steady position, having eye-hand-mouth coordination with food (looking at food and wanting to grab it) and lastly that they are able to manage food in their mouth (babies who are not ready will push their food back out with their tongue). It is important not to miss these cues with your baby and rather follow your baby’s development for readiness for food introduction.

Babies start mouthing usually from 3 months of age, this means they are putting their fists/fingers in their mouth and can often be associated with a lot of salivation. This often gets misinterpreted as either early teething or that they are hungry. In fact, this is a wonderful developmental stage that all children go through, desensitizing their mouth for future solids and also learning to explore. In future you will not only see them explore their fingers in this way, but foods and toys as well. Similarly often parents interpret night time waking, when they have slept through as a sign to wean, when there are none of the other signs (i.e. eye-hand-mouth coordination ect)  present. Babies will go through these periods naturally, so it is not necessarily a sign that they need food.

So look and listen to your baby’s cues and start when your baby is ready, but remember never before 17 weeks! I will guide you through weaning with future posts.